Asthma Patient Counseling: Join the Pharmacist Revolution

Author: Dawn S. Knudsen, PharmD

Patient counseling is part of the
revolution of the pharmacist.
As pharmacists'responsibility
has evolved from dispenser to a disseminator
of information, patient counseling
has become a cornerstone for
pharmaceutical care. Research has
proven that medication adherence
ranges from 20% to 70% for chronic
conditions, such as asthma.1 Pharmacist-provided education can improve
adherence rates and patient understanding.2-4 The National Asthma Education
and Prevention Program recognizes
the need for pharmaceutical care
and recommends that asthma education
be integrated throughout asthma
care.5 Even though patient education is
perceived as important by pharmacists6
and other health care professionals,5 in a 1990s study researchers
reported that between 40% and 67%
of patients do not talk with their pharmacist
about their medications.7 Even
though pharmacists are specifically
trained to provide medication education,
patients may lack an understanding
about the expanded counseling
function that pharmacists possess.7
Because patients lack awareness of this
skill, it is up to pharmacists to open the
door of communication when providing
counseling about asthmatic treatments.

Important Points to Cover

Most patients do not have a completely
correct inhaler technique,
which may lead to less than optimal
delivery and suboptimal efficacy of the
medication. The majority of retail pharmacists
who provide patient counseling
are very busy and are being pulled
in several different directions; quick and
concise counseling techniques are necessary.

DIPS [Dosage, Instructions,Priming, Special Instructions] is an
easy-to-remember acronym that covers
most of the important parts regarding
correct use of inhalers.

DIPS

D. Is the patient going to be using 1
or 2 inhalations? Will the dosage be
scheduled or as needed? This is also an
easy transition to discuss the indication
of the medicationrescue, longterm
control, or combination product.
If a bronchodilator and maintenance
medications are prescribed, the patient
needs to use the bronchodilator
first, wait 5 minutes, and then use the
maintenance inhaler.

I. The instructions can vary according
to which delivery system is being
used. Metered dose inhalers (MDIs)
require coordination, which can be difficult
for small children and the elderly.
The patient needs to breathe out and
press down on the canister while
breathing in. Patients
should hold this breath for
up to 10 seconds, or as
long as they are comfortable.
The patient needs to
shake the inhaler and wait
approximately 1 minute
between inhalations, if
multiple inhalations are
prescribed.8 Most companies
can provide placebo
versions of their inhalers
upon request. The use of a
placebo inhaler can be very
helpful when demonstrating
correct inhaler technique. The
patient should subsequently be able to
demonstrate the technique, as most
people do not have questions or do not
discover problems until the first use of
a product.

Dry powder inhalers may be more
patient-friendly and do not require the
patient to coordinate breathing and
product delivery. The patient does need
to keep the inhaler parallel to the
ground after the dose has been
released to keep the powder in the
delivery channel before inhalation. Be
sure to warn the patient that humidity,
including patient breath, can cause the
powder to clump together. Patient
exhalation into the device prior to
inhalation can also cause that dose to
exit the device.

P. MDIs require priming (ie, 2 to 4
sprays in the air) before use if the
product is new or unused for a certain amount of time (Table). If the
patient does not prime the device,
less than the desired dose of active
ingredient may be received. Educate
patients that this is an important part
of inhaler use, especially if they use
their rescue albuterol inhaler infrequently.
Dry inhalers require no such
priming.

S. Inhalers are like no other delivery
device and have special instructions
for each type of device. Some relatively
new inhaler devices require special
instructions (eg, some are breath-actuated,
and some require capsules
to be inserted into the device). For
inhalers that require capsules, patients
need to be aware that the capsule is
not to be ingested and needs to be
replaced with each use. For MDIs, the
correct amount of medication in each
canister is measured in a certain
amount of actuations. After that specific
number of actuations, even
though the canister does not feel completely
empty, the canister should be
discarded. Placing an inhaler in water
to see if it floats does not indicate if
the canister is emptythis is no
longer considered appropriate or accurate.
Patients need to rinse and spit
following the inhalation of corticosteroids,
because MDIs may also lead
to oropharyngeal deposition, which
can cause hoarseness and thrush.
Cleaning of inhalers is not necessary;
wiping with a moist, clean rag is
sufficient.

Areas of Patient Confusion

"My asthma medication isn't working"
is a common statement pharmacists
should expect to hear. This statement
should lead pharmacists to check
patient inhaler technique and use
open-ended questions to discover the
problem.9

Language Barrier

Patients and health care providers
have different definitions for commonly
used medical terminology.10 A patient
may define controller or longtermcontroller as a medication that
controls symptoms, and he or she will
use this medication when symptoms
occur that need to be controlled.
Rescue medication can have different
meanings to the patient and provider.
The phrase "rescue medications open
the airways" is often used to describe
the mechanism of action of the rescue
medication. The patient may misunderstand
that the force of the product
exiting the inhaler inflates the lungs.

Expectations

Patients'expectations also affect
how they view the efficacy of their
medication. Patients may expect to feel
or taste the medication when they inhale,
and if correct technique is used
this should not occur. Patients may
anticipate feeling systemic side effects,
such as heart palpitations or excitation.

To correct or prevent incorrect inhaler
technique, ask patients to describe
under what circumstances they
use each medication, provide verbal
and written education, and demonstrate
proper techniques.